By AACVPR President Ana Mola, PhD, RN, ANP-BC, MAACVPR | October 30, 2019

Recently, the American Heart Association (AHA) released a news article “Understanding Bernie Sanders' Heart Treatment” that highlighted the Democratic presidential candidate’s recent cardiac event. While the article well explained what happened to Sanders, it is missing one important aspect: that Cardiac Rehabilitation (CR) should be a Myocardial Infarction (MI) and Percutnaeous Coronary Intervention (PCI) post procedure recommended referral for all eligible patients.

CR is a strong clinical utility of secondary prevention of ischemic heart disease. There is strong scientific evidence that comprehensive, multidisciplinary CR services confirm the benefits of exercise-based CR within the context of current optimal cardiovascular medical therapy and service provision. Numerous national and international scientific statements and clinical practice guidelines endorse CR for chronic stable angina, systolic heart failure, MI, PCI and cardiac surgery.

The public knowledge and extensive media coverage of Sanders’ PCI provides a teachable moment for patients, family members and clinicians to gain knowledge of the CR benefits after a cardiac event and a PCI. A 2011 retrospective analysis showed us that patients who underwent CR demonstrated reduced mortality rates regardless of gender or age, both for elective and non-elective PCI.¹ Despite evidence like this, the CR referral of patients with PCI have been historically low. In a study by Aragam et al. (2015) the CR referral rate was between 59%-66% for 1.5 million PCI patients, including a subset who presented initially with a MI. This CR referral rate is still too unacceptably low.²

Along with reduced morbidity and mortality, CR also leads to a reduction of hospital readmissions and improvement in functional status and quality of life. These are predicated on the results of exercise training, psychological counseling and a focus on preventative strategies (e.g. medication adherence, cardiac risk factor modification).

CR is also cost effective, confirming the return on financial investments associated with patients’ participation in CR and their improved clinical outcomes. The scientific evidence has demonstrated over decades the benefits of CR which has led CR to be designated as a quality indicator and performance measure for referral. CR has sparked quality improvement initiatives, such as the American Heart Association’s “Get with the Guidelines” program, to increase CR referral systematically.

This low CR referral for PCI and other CR eligible diagnoses highlights the potential gap for hospital-level interventions to improve these referral rates. To address this gap, in 2015, the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC) and AACVPR established the Million Hearts Cardiac Rehabilitation Collaborative. This Collaborative has set a goal to increase referral to CR programs from 20% to 70% by 2022. If this goal is achieved, 25,000 lives would be saved, including the prevention of 180,000 hospitalizations annually in the U.S.³

The Bernie Sanders’ cardiovascular event is the perfect story to educate the populace in the benefits of CR after a cardiac event. Let’s take this opportunity to make a difference and add a greater reach for CR through Senator Sanders’ experience and recommend that CR would benefit him and others in the same circumstance. 

1. Goel K, Lennon RJ, Tilbury RT, Squires RW, Thomas RJ. (2011). Impact of cardiac rehabilitation on mortality and cardiovascular events after percutaneous coronary intervention in the community. Circulation. 123(21):2344-52.
2. Aragam KG, Dai D, Neely ML, Bhatt DL, Roe MT, Rumsfeld JS, Gurm HS (2015). Gaps in referral to cardiac rehabilitation of patients undergoing percutaneous coronary intervention in the United States. Journal of American College of Cardiology. 19;65(19):2079-88. doi: 10.1016/j.jacc.2015.02.063.
3. Ades PA, Keteyian SJ, Wright JS, Hamm LF, Lui K, Newlin K, Shepard DS, Thomas RJ. (2017). Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clinic Proceedings. 92(2):234-242. doi: 10.1016/j.mayocp.2016.10.014.